1. Field of the Invention
The present invention relates to software and hardware systems for proactively monitoring and managing the health care of a population of member patients. More particularly, the present invention relates to a proactive system in which medical data are periodically gathered and, based on medical data indicating a risk situation, Coordination Specialists are notified and provided with information enabling them to take specific actions to avoid unintended health care utilization and/or health care process failures.
2. Description of the Related Art
Conventional systems for providing health care services operate mainly in response to existing health problems. For example, in such reactive systems, a patient experiencing health problems must initially schedule an appointment with a physician for evaluation of the problems. During the appointment, the physician evaluates the patient, the patient is treated by the physician or is referred to a specialist physician for treatment, and the patient is prescribed medicine or other types of follow-up care/treatment.
Accordingly, the effectiveness of conventional reactive systems in their ability to maintain patient health depends heavily upon patient responsibility. For example, conventional systems require a patient to determine when to seek medical help, to determine where to go for help (physician""s office, outpatient clinic, hospital, emergency room, etc.), to understand his condition and his role in treatments), to comply with prescribed treatment, and to manage multiple conditions and corresponding treatments simultaneously. In a case that any of these functions is poorly performed, the health of the patient is jeopardized and additional health care expenditures are likely to be necessary.
Conventional systems also require several physicians or other care providers to care for a particular patient. In some of these systems, for example, a primary care physician focuses on diagnosis and development of a treatment plan, a specialist physician focuses on a particular specialty area, a surgeon performs needed surgeries, and a home health care provider delivers home-based treatment and support. However, conventional systems often fail to cooperatively execute each of the above health care processes, most often due to a lack of communication among the various care providers.
As a result of the foregoing, conventional health care systems are susceptible to several types of process failures. These failures often lead to lower quality of care and higher health care costs. In one type of process failure, a patient fails to fulfill his responsibilities in managing his condition or executing his health care regimen. Specifically, a patient with hypertension may not properly manage his condition by lowering his sodium intake, or a patient with dementia and no caregiver support may be unable to properly manage multiple prescribed medications.
Another type of process failure occurs when health care is not consistently delivered to patients with progressive chronic conditions. For example, a patient with heart problems who is taking blood-thinning agents may fail to undergo required periodic lab tests due to either patient non-compliance or neglect on the part of the primary care physician. In another example, a patient with diabetes, at risk for deteriorating vision, may fail to attend annual eye examinations.
Communication failures are another type of process failure and occur between various care providers. In one instance, due to a lack of communication with a patient""s primary care physician, a hospital-based physician may prescribe care for an elderly patient that is in conflict with the primary care physician""s treatment plan and understanding of the patient. In another instance, a specialist may perform lab tests identical to those previously performed by a primary care physician because he is unaware of the previous tests or because he does not have access to the results of the previous tests.
Failures in task execution may occur even if communication between various providers is successful. For example, even though instructions are issued to provide a wheelchair to the home of a discharged patient, those instructions may not be carried out, or may be carried out several days too late. In either case, the health of the patient is jeopardized.
Improper utilization of health care resources is another common type of process failure. For example, a patient with a chronic condition and poor understanding of the health care system may use the emergency room for health care services when other options would be more appropriate and much less costly. In another example, improper utilization of resources also may occur when a patient ignores serious symptoms of disease and, as a result, fails to seek care. In this latter case, the health of the patient is endangered and the potential costs of future care for that patient may increase substantially.
Finally, conventional health care systems are effective only if providers follow accepted standards of care, whether in prescribing medicine, rehabilation, or other treatment. If such standards are not followed, patient health is jeopardized even if all other aspects of the system function properly.
As a result of the prevalence of process failures in conventional health care delivery systems, health care providers, health maintenance organizations (HMOs), and medical insurance companies are attempting to create and enforce strict protocols to deal with health problems once they occur, and to perform limited preventive care for certain individuals. However, these conventional protocols have not adequately improved the health of individuals subject to the protocols, nor have they sufficiently reduced health care costs.
In order to address the foregoing problems, the present Applicants have discovered that certain combinations of patient characteristics and medical events concerning a patient indicate that the patient is at risk of incurring medical costs due to an avoidable process failure of the health care system. Such combinations are hereinafter referred to as xe2x80x9crisk situationsxe2x80x9d. Moreover, Applicants have invented a system which detects risk situations and allows care providers to proactively address avoidable process failures that correspond to the risk situations.
Advantageously, the present invention allows proactive intervention in cases where the cost of preventing a process failure is less than the cost incurred if the failure occurs, as reduced by the probability of the failure occurring without the intervention. Accordingly, the present invention provides a flexible and proactive system to improve the health of a population of member patients and to lower the costs of caring for the population. The system also provides proactive intervention in cases where the above cost-benefit relationship is not satisfied, but where intervention is nonetheless desired, such as to meet a regulatory requirement.
More specifically, a system for managing health care of a member population according to the present invention preferably includes periodic monitoring of a member population for member characteristics and/or medical events, identification of opportunities to assist members in managing their health and in navigating through the health care system based on combinations of member characteristics and/or medical events, and identification, based on combinations of member characteristics and medical events, of opportunities to assist physicians and other care providers in properly delivering health care services.
A system according to the invention also preferably includes proactive, cost-effective, and coordinated patient interventions to address the identified opportunities, as well as-proactive interventions with physicians and providers to assist them in managing care and in coordinating the activities of various care providers.
FIG. 1 is a representative block diagram of a system according to the present invention. As shown, member characteristics 10 are obtained from member surveys 11, health care providers 12, historical health care data 13, such as laboratory data, pharmacy data, or claims data, while data concerning medical events 14 are periodically obtained from data sources such as laboratories 15, pharmacy benefits managers 16, insurance companies 17, health plans 18, or hospitals 19. Based on a detected combination of member characteristics 10 and/or medical events 14 indicating a risk situation, notification 20 is generated.
Notification 20 is sent to Coordination Specialist 21 and may also include information used to update member characteristics 10. Coordination Specialist 21 is preferably a medically-trained individual who is responsible for monitoring and managing a particular subset of the member population. As a result, it is beneficial for Coordination Specialist 21 to receive any notifications regarding members of the subset. As will be described, the system also provides Coordination Specialist 21 with access to a wide range of medical data concerning members of the subset, as well as instructions and tools to manage the health care of the members.
Also sent with notification 20 is information concerning an intervention which should be performed by Coordination Specialist 21. The intervention is designed to address an avoidable process failure corresponding to the indicated risk situation indicated by notification 20. In order to execute the intervention, Coordination Specialist 21 may be required to contact physician 22, disease-specific case manager 23, member 24, hospital 25, durable medical equipment provider 26, health plan 29, or another health care-related entity, or to refer to education resources 27 or arrange community resources 28. It should be noted that notification 20 and/or its associated intervention(s) may be sent directly to any of the above health care-related entities or other entities utilizing the present invention.
Accordingly, in one aspect, the present invention is a system for managing health care of a plurality of members in which member characteristics of a member are identified, a list of the member characteristics are stored, information indicative of a medical event is continuously monitored, information indicative of a medical event is obtained, and a risk situation is automatically identified based on the member characteristics and the medical event information. A notification is generated in response to the identified risk situation, wherein the notification is accompanied by a predetermined script, or Standard Operating Procedure (SOP), designed to address the identified risk situation. Preferably, the risk situation corresponds to a potential process failure in the delivery of health care to the member.
In even greater detail, the present invention is a system for managing health care processes in which member characteristics of each member of a patient population are determined from member surveys, care providers, insurance claim data, historical health care data or the like, and medical events are periodically detected from laboratory data, pharmacy benefits manager data, hospital data, physician records, home health care data, direct conversations with members and physicians, health plan data or other sources.
The detected medical events and member data are received at a centralized location, where they are linked to individual members using a master person index, and stored in a database based on the linkages. Next, member data and medical events corresponding to a member are assessed to determine whether there exist risk situations which indicate a potential process failure in the health care system.
For example, the following combinations of member characteristics and/or medical events represent risk situations: diabetes, hypertension and high sodium levels, dementia and no caregiver support, heart problems and no prescribed beta blockers, discharge of an elderly patient who lacks caregiver support, and presence of a chronic condition, a hospitalization medical event, and no caregiver support.
Upon identifying a risk situation, a notification is sent to a Coordination Specialist and/or to another selected entity. The notification specifies the risk situation and includes a coordination plan that provides relevant information to the Coordination Specialist and guides appropriate intervention processes. Such a notification may be delivered via Internet, Intranet, or other means. Received notifications are preferably prioritized based on their urgency.
In order to respond to a notification, the Coordination Specialist performs steps of a particular SOP corresponding to the coordination plan. The SOP details specific steps to address the risk situation represented by the notification, and may include direction of the member to community resources, education of the member, or a further assessment of the member""s characteristics, the results of which can then be used to update the member""s characteristics. The SOP may also result in automatic facsimile transmission of medical and coordination information to a provider, generation of reminder letters, or provider paging.
A preferred embodiment of the invention also includes software applications which allow care providers to enter referrals, provide additional information, check recent activities, order tests, or the like. Such events are detected by the system and are assessed to update member characteristics and/or to generate notifications.
As an example of the foregoing, a case is considered in which a particular member""s characteristics include lack of a caregiver. In one embodiment of the invention, hospitalization and lack of a caregiver are a combination indicating a risk situation. Accordingly, in a case that the member is hospitalized for knee replacement surgery, a xe2x80x9chospitalizationxe2x80x9d medical event is detected. Next, the system identifies the presence of the hospitalization/lack of a caregiver risk situation and generates a corresponding notification.
A Coordination Specialist receives the notification and is directed to perform an SOP based on the notification. The SOP may include steps such as confirming a discharge plan, education for the member, and the securing of durable medical equipment for the member, such as a wheelchair.
More specifically, FIG. 2 is a flow diagram of process steps executed by a Coordination Specialist according to the present invention. Initially, in step S201, the Coordination Specialist logs on to the system via a computer terminal. Next, in step S202, the Coordination Specialist reviews a displayed list of notifications received by the system since a previous logon. Preferably, the list also includes notifications not yet acted upon by the Coordination Specialist. The notifications may be sorted according to urgency, notification type, or in an alphabetized list of affected members.
In step S204, the Coordination Specialist selects a member corresponding to one of the displayed notifications. This selection causes the system to present data regarding the notification to the Coordination Specialist. Eligibility information for the member is then checked in step S205 to determine the insurance eligibility status of the member. Next, in order to obtain an overview of relevant information, the Coordination Specialist reviews member characteristics of the selected member in step S206. As described above, the characteristics may include such characteristics as terminal illness, substance abuse, reliance on a caregiver, failure to seek care, or the like.
In step S207, the Coordination Specialist examines whether an intervention history for the member is available. If so, flow proceeds to step S209, wherein the intervention history is displayed and reviewed by the Coordination Specialist to obtain a clearer understanding of the member""s current health situation. Flow continues from either step S207 or S209 to step S210, at which point the Coordination Specialist reviews other data related to the member, such as medication data, encounter data, or assessment data. The Coordination Specialist also views, in step S211, the actual questions and answers of a member health survey previously received from the member.
In step S212, the Coordination Specialist reviews and implements interventions based on SOPs of a notification corresponding to the member selected in step S202. As described above, an intervention may consist of contacting the member, the member""s primary physician, a related provider, community resources, a pharmacy benefits manager, or the like. After performing the intervention, in step S214, the Coordination Specialist completes a coordination plan and notes the time required to complete the intervention in an intervention summary for the completed intervention, the information of which is thereafter recorded within an intervention history for the member.
In step S215, the Coordination Specialist updates the member characteristics for the member. Alternatively, based on information obtained during the intervention, the system may automatically update the member characteristics. Lastly, the Coordination Specialist removes the processed notification in step S216 and selects a next member in step S217.
The foregoing process steps advantageously provide fast, informed, and proactive management of member""s health situations. As a result, the present invention can improve member health while reducing health care costs.